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sb/hs/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyz D. Dlmn / M / 25 yrs.
Referred by : Dr. Abc Xyzisheri.
Examination : M.R.I. of the Dorsal Spine.

CLINICAL PROFILE :

H/O paresthesias in BLE since 15 days.
C/O weakness of BLE with bladder/bowel involvement since 2 days.

EXAMINATION :

M.R.I of the dorsal spine was performed using the following parameters :

4 mm thick T1 Weighted and T2 Weighted sagittal images.

6 mm thick T1 Weighted and T2 Weighted axial images.

OBSERVATION :

There is seen a fairly large, well-marginated, expansile mass lesion involving the spinous process, laminae and the right sided transverse process and right pedicle of the D4 vertebra and also the right lamina, right pedicle and transverse process of the D5 vertebra. This lesion is of intermediate signal on the T1 Weighted images and appears heterogeneously hyperintense on the T2 Weighted images. There is resultant extension into the posterior and right lateral epidural space at the D4 vertebral level with resultant cord compression. The dorsal spinal cord at D4 and D5 levels shows a hyperintense signal on the T2 Weighted images which suggests cord edema/ischemia. There is also extension of the lesion into the right neural foramen at the D4-D5 level and into the right posterior paraspinal soft tissues at the D4 and D5 vertebral levels.

The rest of the visualized upper dorsal vertebral bodies and intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
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A suspicious enlarged lymphnode is noted at the right hilum.

Screening, T1 Weighted sagittal images of the lumbar spine reveal small right paracentral disc herniations at the L2-L3 and L3-L4 levels and a small postero-central protruded disc at the L4-L5 level.

IMPRESSION :

A fairly large, well-marginated, expansile mass lesion involving the spinous process, laminae and the right sided transverse process and right pedicle of the D4 vertebra and also the right lamina, right pedicle and transverse process of the D5 vertebra as described is not specific for a single etiology. This lesion may either represent a neoplasm like a round cell tumor or posterior element infective/inflammatory lesion like tuberculosis. There is resultant cord compression and cord signal alteration as described suggesting cord edema/ischemia. A suspicious enlarged right sided hilar lymphnode is noted.
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